Ideas and Innovations

Pediatric/Craniofacial
Establishing a Protocol for Closed Treatment
of Mandibular Condyle Fractures with
Dynamic Elastic Therapy
George N. Kamel, MD*
Brandon J. De Ruiter, BS*
Daniel Baghdasarian, BS*
Evan Mostafa, BS*
Avinoam Levin, BA*
Edward H. Davidson, MD†
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Summary: Treatment of mandibular condyle fractures is controversial. Open treat-
ment achieves anatomic reduction with occlusal stability and faster functional
recovery but risks facial nerve injury and jeopardizes joint capsule circulation
which can lead to bone resorption. Traditional closed treatment avoids these issues
but requires prolonged fixation and risks subsequent facial asymmetry, occlusal
disturbance, and ankylosis. Rather than wires, closed treatment with elastics allows
for customizable management of a healing fracture with ability to alter vector and
degree of traction to restore vertical height and occlusion with less discomfort and
decreased risk for ankylosis. In this protocol, unilateral condylar fractures were

treated with class II elastics ipsilateral to injury and class I contralaterally. Class
III elastics were used contralaterally if additional traction was required and Class
II elastics were placed bilaterally for bilateral fractures. Patients were sequentially
advanced from fixating to guiding to supportive elastics by titrating elastic vector to
any dental midline incongruency or chin deviation. Six patients were treated with
this protocol with six-month follow-up. Fracture patterns included displaced and
dislocated fractures as well as intracapsular and extracapsular condylar fractures.
All patients at completion of the protocol had objective centric occlusion with no
subjective malocclusion, chin deviation, facial asymmetry, or temporomandibular
joint pain. These early data demonstrate a safe and efficacious innovative protocol
for closed treatment of mandibular condylar fractures with dynamic elastic therapy.
(Plast Reconstr Surg Glob Open 2019;7:e2506; doi: 10.1097/GOX.0000000000002506;
Published online 20 December 2019.)

INTRODUCTION closed treatment avoids these issues but requires pro-

Management of mandibular condyle fractures is con-
troversial.1 Open treatment achieves anatomic reduction
with occlusal stability and faster functional recovery but
risks facial nerve injury and jeopardizes joint capsule cir-
culation which can lead to bone resorption.2–6 Traditional
From the *Division of Plastic and Reconstructive Surgery,
Montefiore Medical Center/Albert Einstein College of Medicine,
New York, N.Y.; and †Department of Plastic and Reconstructive
Surgery, Case Western Reserve University, Cleveland, Ohio.
Received for publication August 21, 2019; accepted August 30,
2019.
Presented at The American Society of Plastic Surgeons (ASPS)
87th Annual Meeting, September 28, 2018, Chicago, Ill. and The
Northeastern Society of Plastic Surgeons (NESPS) 35th Annual
Meeting, October 26, 2018, Boston, Mass.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
DOI: 10.1097/GOX.0000000000002506
longed fixation and risks subsequent facial asymme-
try, occlusal disturbance, ankylosis, and degenerative
changes.6–11
Traditional closed treatment employs rigid wired
arch bars to achieve maxillomandibular fixation.1,12–16
Rather than wires, closed treatment with elastics permits
functional movement and allows customizable manage-
ment of a healing fracture with ability to alter vector and
degree of traction potentiating better healing, decreased
discomfort, and decreased risk for ankylosis (see figure,
Supplementary Digital Content 1, which details vector
design, http://links.lww.com/PRSGO/B261).9,10,16,17 Prior
studies on elastics are limited to case reports,18–22 pedi-
atric studies,16,18,20–22 or describe it as an adjunct to open
therapy.23,24 Furthermore, there is significant variation in
methodology.18–20,22–25 The aim of this study was to present
Disclosure: The authors have no financial interest to declare
in relation to the content of this article.
Related Digital Media are available in the full-text
­version of the article on www.PRSGlobalOpen.com.

www.PRSGlobalOpen.com 1
 PRS Global Open • 2019

a novel elastics protocol for closed treatment of condylar
fractures.
METHODS
A 1-year single-center prospective study of patients
with radiographic evidence of condyle fracture and mal-
occlusion at presentation was conducted (those younger
than 16 years of age or edentulous status were excluded).
All patients with extracondylar fractures (eg, symphyseal
or parasymphyseal) underwent open reduction and inter-
nal fixation of those injuries. Condyle fractures (including
condylar head, neck, and subcondylar) were managed with
patients being placed in arch bars and elastics in three pro-
tocol phases (see figure, Supplementary Digital Content 2,
which details elastic classification, http://links.lww.com/
PRSGO/B262). Elastics nomenclature is per orthodontic
convention (see figure, Supplementary Digital Content 3,
which details elastic classification, http://links.lww.com/
PRSGO/B263).
Protocol
Phase I: Fixating Elastics
For patients with unilateral condyle fractures, class II
elastics were placed ipsilateral to injury and class I con-
tralaterally. Figure-of-eight 6 oz ¾ inch bands were placed
to maintain sufficient vector to reestablish maximal inter-
cuspation, midline congruency, and fully restrict mouth
opening. In patients with severe displacement or disloca-
tion of the condyle, class III elastics were used in place of
class I on the contralateral side to further increase yaw and
traction. Patients with bilateral condylar fractures received
class II elastics bilaterally. Patients were maintained on a
liquid diet. At 2-week follow-up, patients were evaluated
for malocclusion or chin deviation and advanced to phase
II if clinically eligible.
Phase II: Guiding Elastics
In phase II, patients were transitioned to guiding elas-
tics with 6 oz ¼ inch bands placed in the same orientation
as phase I. Elastics were no longer placed in a figure-of-
eight configuration which thus permitted limited (<1 cm)
mouth opening. Patients were instructed on replacement
of their elastics and advanced to a blenderized diet. After
2 weeks, patients were evaluated for malocclusion or chin
deviation and advanced to phase III if clinically eligible.
Phase III: Supportive Elastics
In phase III, 6 oz ¼ inch bands were again used but
with class I orientation bilaterally. Patients were advanced
to soft diet. After 2 weeks, patients were assessed for mal-
occlusion or chin deviation and arch bars were removed if
clinically eligible.
Patients with malocclusion or chin deviation at any
phase of protocol were not advanced, but rather main-
tained in phase or reverted to a prior phase as appropri-
ate. These patients underwent weekly assessment and
advancement held until maximal intercuspation and mid-
line congruency were achieved.
RESULTS
Patient demographics (n = 6) and fracture character-
istics are shown in Table 1. Five patients advanced succes-
sively through the protocol without issue. One patient
demonstrated chin deviation and subjective malocclusion
at two-week follow-up. This was corrected by maintaining
fixating elastics for an additional 2 weeks and replacing
class I elastics on the right side with class III and then
advancing to supportive elastics.
At conclusion of therapy, all patients demonstrated
maximal intercuspation without chin deviation, facial
asymmetry, or TMJ pain. Average number of postoperative
visits was four. Duration of therapy was six weeks. Mean
follow-up was sixty-six days (range: 39–133).
DISCUSSION
There are advocates for both open and closed treat-
ment of adult condylar fractures. Al-Moraissi and Ellis6
championed open treatment citing superior functional
outcomes. Some have claimed open techniques are prefer-
able for treatment of displaced or dislocated fractures due
to concern that traditional closed methods impart insuf-
ficient traction to reduce fracture segments.25–31 Others
have advocated avoiding open treatment when possible to
avoid operative risks including bleeding, infection, nerve
damage, and scarring.32 Along with these considerations,
fracture location is important to selection of therapy as
intracapsular fracture exposure is more difficult and bears
increased risk for facial nerve injury.31,33 Therefore, sub-
condylar and extracapsular condylar neck fractures or
those that are significantly dislocated or displaced are

Table 1. Characteristics of the Study Population

Smoking Fracture Fracture Secondary Fracture Duration of
Age (y) Sex BMI Status Location Laterality Fracture Alignment* Location Follow-up (d)
17 F 19.7 Never Subcondylar Right Mild displacement and no dislocation Symphysis 47
51 F 19.0 Active Condylar neck Left Moderate displacement and no dislocation — 133
28† F 25.2 Never Subcondylar Left Moderate displacement and no dislocation — 59
24 M 20.4 Former Subcondylar Left Mild displacement and no dislocation Parasymphysis 39
26 M 23.6 Active Subcondylar Left Mild displacement and no dislocation Parasymphysis 53
48 M 19.9 Former Condylar head Bilateral Severe displacement bilaterally and Symphysis 65
dislocated bilaterally
*Severity of displacement was graded based on the following scale: mild displacement (>50% cortical overlap between fracture segments), moderate displacement
(<50%), and severe displacement (no cortical overlap).
†This patient presented with subjective malocclusion and leftward chin deviation at 2-week follow-up. She was therefore retained in fixating elastics for an addi-
tional 2 weeks and had the class I bands on the side contralateral to her fracture replaced with class III bands. Malocclusion and chin deviation were resolved at
2-week follow-up, and she was advanced to guiding elastics per protocol.

2
Kamel et al. • Dynamic Elastics for Condyle Fractures
arguably more amenable to open treatment, whereas
intracapsular fractures of the condylar head and fractures
that are minimally dislocated or displaced are more suited
to closed methods. Despite this rationale, limitations to
each method remain.34,35
The ideal treatment would combine the safety of closed
treatment with the ability to achieve anatomic alignment
afforded by open treatment while avoiding the need for
prolonged maxillomandibular fixation. Treatment with
elastics avoids open procedure while permitting customiz-
able vector design with ability to actively traction fracture
segments out to length and permitting functional move-
ment that avoids rigid fixation, limits discomfort, and
permits better bone healing.9,10,16,17 In the present study,
all patients were successfully managed with elastics and
were able to avoid rigid immobilization. Preinjury occlu-
sion and midline congruency were reestablished regard-
less of the degree of displacement and all avoided open
procedure.
Although more superior condyle fractures should
require shorter fixation than those that are anatomically
inferior, in this study we implemented a standardized
6-week protocol with each phase requiring at least two
weeks of treatment based on experience from prelimi-
nary work.
In this study, two active smokers followed this protocol
and achieved good functional outcomes without deviation
or malocclusion. Given the negative effects of smoking on
osseous healing,19,20 our recommendation for active smok-
ers is to maintain supportive phase until resolution of ten-
derness at the fracture site.
After the fixating phase, patients are permitted to
replace their elastics at home, but must demonstrate
understanding and application of elastics. Patient selection
is therefore important to avoid treatment inaccuracies.
CONCLUSION
This study demonstrates a safe and effective protocol
for closed treatment of mandibular condyle fractures with
dynamic elastic therapy.
Edward H. Davidson, MD
Department of Plastic and Reconstructive Surgery
Case Western Reserve University
11100 Euclid Avenue
Lakeside 5206
Cleveland, OH 44106
E-mail: edward.davidson@uhhospitals.org
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